1
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Omotoye S, Singleton MJ, Zagrodzky J, Clark B, Sharma D, Metzl MD, Gallagher MM, Meininghaus DG, Leung L, Garg J, Warrier N, Panico A, Tamirisa K, Sanchez J, Mickelsen S, Sardana M, Shah D, Athill C, Hayat J, Silva R, Clark AT, Gray M, Levi B, Kulstad E, Girouard S, Zagrodzky W, Montoya MM, Bustamante TG, Berjano E, González-Suárez A, Daniels J. Mechanisms of action behind the protective effects of proactive esophageal cooling during radiofrequency catheter ablation in the left atrium. Heart Rhythm O2 2024; 5:403-416. [PMID: 38984358 PMCID: PMC11228283 DOI: 10.1016/j.hroo.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2024] Open
Abstract
Proactive esophageal cooling for the purpose of reducing the likelihood of ablation-related esophageal injury resulting from radiofrequency (RF) cardiac ablation procedures is increasingly being used and has been Food and Drug Administration cleared as a protective strategy during left atrial RF ablation for the treatment of atrial fibrillation. In this review, we examine the evidence supporting the use of proactive esophageal cooling and the potential mechanisms of action that reduce the likelihood of atrioesophageal fistula (AEF) formation. Although the pathophysiology behind AEF formation after thermal injury from RF ablation is not well studied, a robust literature on fistula formation in other conditions (eg, Crohn disease, cancer, and trauma) exists and the relationship to AEF formation is investigated in this review. Likewise, we examine the abundant data in the surgical literature on burn and thermal injury progression as well as the acute and chronic mitigating effects of cooling. We discuss the relationship of these data and maladaptive healing mechanisms to the well-recognized postablation pathophysiological effects after RF ablation. Finally, we review additional important considerations such as patient selection, clinical workflow, and implementation strategies for proactive esophageal cooling.
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Affiliation(s)
| | | | - Jason Zagrodzky
- St. David’s Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas
| | | | | | - Mark D. Metzl
- NorthShore University Health System, Evanston, Illinois
| | - Mark M. Gallagher
- St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | | | - Lisa Leung
- St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Jalaj Garg
- Loma Linda University Medical Center, Loma Linda, California
| | - Nikhil Warrier
- MemorialCare Heart & Vascular Institute, Fountain Valley, California
| | | | - Kamala Tamirisa
- Cardiac Electrophysiology, Texas Cardiac Arrhythmia Institute, Dallas, Texas
| | - Javier Sanchez
- Cardiac Electrophysiology, Texas Cardiac Arrhythmia Institute, Dallas, Texas
| | | | | | - Dipak Shah
- Ascension Providence Hospital, Detroit, Michigan
| | | | - Jamal Hayat
- Department of Gastroenterology, St George’s University Hospital, London, United Kingdom
| | - Rogelio Silva
- Department of Medicine, Division of Gastroenterology, University of Illinois at Chicago, Chicago, Illinois
- Advocate Aurora Christ Medical Center, Chicago, Illinois
| | - Audra T. Clark
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Benjamin Levi
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Erik Kulstad
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | | | | | - Enrique Berjano
- Department of Electronic Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Ana González-Suárez
- Translational Medical Device Lab, School of Medicine, University of Galway, Galway, Ireland
- Valencian International University, Valencia, Spain
| | - James Daniels
- University of Texas Southwestern Medical Center, Dallas, Texas
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2
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Yoshimura S, Take Y, Kaseno K, Goto K, Matsuo Y, Aoki H, Sasaki T, Miki Y, Nakamura K, Naito S. Characteristics of radiofrequency lesions in patients with symptomatic periesophageal vagal nerve injury after pulmonary vein isolation. J Arrhythm 2024; 40:510-517. [PMID: 38939771 PMCID: PMC11199810 DOI: 10.1002/joa3.13036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 02/21/2024] [Accepted: 03/28/2024] [Indexed: 06/29/2024] Open
Abstract
Background Periesophageal vagal nerve injury (PNI) is an unpredictable and serious complication of atrial fibrillation (AF) ablation. We aimed to identify the factors associated with symptomatic PNI. Methods This study included 1391 patients who underwent ablation index-guided pulmonary vein isolation (PVI) using the CARTO system. The target ablation index was set at 550, except for the left atrial (LA) posterior wall near the esophagus, where radiofrequency (RF) power and duration were limited. Ten patients (0.72%) were diagnosed with symptomatic PNI. We randomly selected 40 patients without PNI (1:4 ratio) matched based on age, sex, body mass index, LA diameter, type of AF, and esophageal location. We measured the shortest distance from the RF lesions to the esophagus (LED) and classified the RF lesions according to the LED into four groups: 0-5, 5-10, 10-15, and 15-20 mm. We conducted a comparative analysis of classified RF lesions between patients with PNI (n = 10) and those without (n = 40). Results The contact force at LED 0-5 mm was significantly higher in patients with PNI than in those without (14.6 ± 1.7 vs. 12.0 ± 2.9 g; p = .01). Multivariate logistic analysis revealed that the independent factor for PNI was contact force at an LED of 0-5 mm (odds ratio: 1.506; 95% confidence interval: 1.053-2.153; p = .025). Conclusions The symptomatic PNI was significantly associated with a higher contact force near the esophagus. Strategies for regulating contact force near the esophagus may aid in the prevention of PNI.
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Affiliation(s)
- Shingo Yoshimura
- Division of CardiologyGunma Prefectural Cardiovascular CenterMaebashiJapan
| | - Yutaka Take
- Division of CardiologyGunma Prefectural Cardiovascular CenterMaebashiJapan
| | - Kenichi Kaseno
- Division of CardiologyGunma Prefectural Cardiovascular CenterMaebashiJapan
| | - Koji Goto
- Division of CardiologyGunma Prefectural Cardiovascular CenterMaebashiJapan
| | - Yuji Matsuo
- Division of CardiologyGunma Prefectural Cardiovascular CenterMaebashiJapan
| | - Hideyuki Aoki
- Division of CardiologyGunma Prefectural Cardiovascular CenterMaebashiJapan
| | - Takehito Sasaki
- Division of CardiologyGunma Prefectural Cardiovascular CenterMaebashiJapan
| | - Yuko Miki
- Division of CardiologyGunma Prefectural Cardiovascular CenterMaebashiJapan
| | - Kohki Nakamura
- Division of CardiologyGunma Prefectural Cardiovascular CenterMaebashiJapan
| | - Shigeto Naito
- Division of CardiologyGunma Prefectural Cardiovascular CenterMaebashiJapan
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3
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Salihu A, Lu H, Maurizi N, Tzimas G, Herrera Siklody C, Le Bloa M, Domenichini G, Teres C, Hugelshofer S, Monney P, Pruvot E, Muller O, Antiochos P, Pascale P. Prevention of esophageal lesions during atrial fibrillation catheter ablation using esophageal temperature monitoring: A systematic review and meta-analysis. Pacing Clin Electrophysiol 2024; 47:614-625. [PMID: 38558218 DOI: 10.1111/pace.14972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 03/04/2024] [Accepted: 03/11/2024] [Indexed: 04/04/2024]
Abstract
INTRODUCTION The use of esophageal temperature monitoring (ETM) for the prevention of esophageal injury during atrial fibrillation (AF) ablation is often advocated. However, evidence supporting its use is scarce and controversial. We therefore aimed to review the evidence assessing the efficacy of ETM for the prevention of esophageal injury. METHODS We performed a meta-analysis and systematic review of the available literature from inception to December 31, 2022. All studies comparing the use of ETM, versus no ETM, during radiofrequency (RF) AF ablation and which reported the incidence of endoscopically detected esophageal lesions (EDELs) were included. RESULTS Eleven studies with a total of 1112 patients undergoing RF AF ablation were identified. Of those patients, 627 were assigned to ETM (56%). The overall incidence of EDELs was 9.8%. The use of ETM during AF ablation was associated with a non significant increase in the incidence of EDELs (12.3% with ETM, vs. 6.6 % without ETM, odds ratio, 1.44, 95%CI, 0.49, 4.22, p = .51, I2 = 72%). The use of ETM was associated with a significant increase in the energy delivered specifically on the posterior wall compared to patients without ETM (mean power difference: 5.13 Watts, 95% CI, 1.52, 8.74, p = .005). CONCLUSIONS The use of ETM does not reduce the incidence of EDELs during RF AF ablation. The higher energy delivered on the posterior wall is likely attributable to a false sense of safety that may explain the lack of benefit of ETM. Further randomized controlled trials are needed to provide conclusive results.
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Affiliation(s)
- Adil Salihu
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Henri Lu
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Niccolo Maurizi
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Georgios Tzimas
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Claudia Herrera Siklody
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Mathieu Le Bloa
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Giulia Domenichini
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Cheryl Teres
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sarah Hugelshofer
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Pierre Monney
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Etienne Pruvot
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Olivier Muller
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Panagiotis Antiochos
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Patrizio Pascale
- Service of Cardiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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4
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Tzeis S, Gerstenfeld EP, Kalman J, Saad E, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01771-5. [PMID: 38609733 DOI: 10.1007/s10840-024-01771-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.
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Affiliation(s)
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Nikolaos Dagres
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Gerhard Hindricks
- Department of Cardiac Electrophysiology, Charité University Berlin, Berlin, Germany
| | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | - Gregory F Michaud
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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5
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Shamloo AS, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O'Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2024:S1547-5271(24)00261-3. [PMID: 38597857 DOI: 10.1016/j.hrthm.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/11/2024] [Indexed: 04/11/2024]
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece.
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil; Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France; Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain; Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA; Case Western Reserve University, Cleveland, OH, USA; Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA; Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología 'Ignacio Chávez', Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O'Neill
- Cardiovascular Directorate, St. Thomas' Hospital and King's College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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6
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Tzeis S, Gerstenfeld EP, Kalman J, Saad EB, Sepehri Shamloo A, Andrade JG, Barbhaiya CR, Baykaner T, Boveda S, Calkins H, Chan NY, Chen M, Chen SA, Dagres N, Damiano RJ, De Potter T, Deisenhofer I, Derval N, Di Biase L, Duytschaever M, Dyrda K, Hindricks G, Hocini M, Kim YH, la Meir M, Merino JL, Michaud GF, Natale A, Nault I, Nava S, Nitta T, O’Neill M, Pak HN, Piccini JP, Pürerfellner H, Reichlin T, Saenz LC, Sanders P, Schilling R, Schmidt B, Supple GE, Thomas KL, Tondo C, Verma A, Wan EY. 2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 2024; 26:euae043. [PMID: 38587017 PMCID: PMC11000153 DOI: 10.1093/europace/euae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 04/09/2024] Open
Abstract
In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .
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Affiliation(s)
- Stylianos Tzeis
- Department of Cardiology, Mitera Hospital, 6, Erythrou Stavrou Str., Marousi, Athens, PC 151 23, Greece
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, University of California, San Francisco, CA, USA
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne and Baker Research Institute, Melbourne, Australia
| | - Eduardo B Saad
- Electrophysiology and Pacing, Hospital Samaritano Botafogo, Rio de Janeiro, Brazil
- Cardiac Arrhythmia Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Jason G Andrade
- Department of Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Tina Baykaner
- Division of Cardiology and Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Serge Boveda
- Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Universiteit Brussel (VUB), Brussels, Belgium
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ngai-Yin Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong Special Administrative Region, China
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shih-Ann Chen
- Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, and Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Ralph J Damiano
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | | | - Isabel Deisenhofer
- Department of Electrophysiology, German Heart Center Munich, Technical University of Munich (TUM) School of Medicine and Health, Munich, Germany
| | - Nicolas Derval
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | | | - Meleze Hocini
- IHU LIRYC, Electrophysiology and Heart Modeling Institute, Cardiac Electrophysiology and Stimulation Department, Fondation Bordeaux Université and Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Young-Hoon Kim
- Division of Cardiology, Korea University College of Medicine and Korea University Medical Center, Seoul, Republic of Korea
| | - Mark la Meir
- Cardiac Surgery Department, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jose Luis Merino
- La Paz University Hospital, Idipaz, Universidad Autonoma, Madrid, Spain
- Hospital Viamed Santa Elena, Madrid, Spain
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA
- Case Western Reserve University, Cleveland, OH, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
| | - Isabelle Nault
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec (IUCPQ), Quebec, Canada
| | - Santiago Nava
- Departamento de Electrocardiología, Instituto Nacional de Cardiología ‘Ignacio Chávez’, Ciudad de México, México
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Mark O’Neill
- Cardiovascular Directorate, St. Thomas’ Hospital and King’s College, London, UK
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | | | - Tobias Reichlin
- Department of Cardiology, Inselspital Bern, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luis Carlos Saenz
- International Arrhythmia Center, Cardioinfantil Foundation, Bogota, Colombia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Agaplesion Markuskrankenhaus, Frankfurt, Germany
| | - Gregory E Supple
- Cardiac Electrophysiology Section, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Atul Verma
- McGill University Health Centre, McGill University, Montreal, Canada
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
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7
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Kaul R, Barbhaiya CR. A Hard Look at EASY AF. JACC Clin Electrophysiol 2024; 10:79-81. [PMID: 38069974 DOI: 10.1016/j.jacep.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 10/19/2023] [Indexed: 01/26/2024]
Affiliation(s)
- Risheek Kaul
- Leon H. Charney Division of Cardiology, New York University Langone Health, New York, New York, USA
| | - Chirag R Barbhaiya
- Leon H. Charney Division of Cardiology, New York University Langone Health, New York, New York, USA.
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8
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Castrejón-Castrejón S, Martínez Cossiani M, Jáuregui-Abularach M, Basterra Sola N, Ibáñez Criado JL, Osca Asensi J, Roca Luque I, Moya Mitjans A, Quesada Dorador A, Hidalgo Olivares VM, Pérez Castellano N, Fernández Gómez JM, Macías-Ruiz MR, Bochard Villanueva B, Gonzalo Bada N, Fernández Prieto A, Guido López LE, Martínez Maldonado ME, Merino D, Escobar Cervantes C, Merino JL. Multicenter prospective comparison of conventional and high-power short duration radiofrequency application for pulmonary vein isolation: the high-power short-duration radiofrequency application for faster and safer pulmonary vein ablation (POWER FAST III) trial. J Interv Card Electrophysiol 2023; 66:1889-1899. [PMID: 36807734 DOI: 10.1007/s10840-023-01509-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/06/2023] [Indexed: 02/21/2023]
Abstract
BACKGROUND Electrical isolation of pulmonary veins (PV) with high-power short-duration (HPSD) radiofrequency application (RFa) may reduce the duration of atrial fibrillation (AF) ablation, without compromising the procedural efficacy and safety in comparison with the conventional approach. This hypothesis has been generated in several observational studies; the POWER FAST III will test it in a randomized multicenter clinical trial. METHODS It is a multicenter randomized, open-label and non-inferiority clinical trial with two parallel groups. AF ablation using 70 W and 9-10 s RFa is compared with the conventional technique using 25-40 W RFa guided by numerical lesion indexes. The main efficacy objective is the incidence of atrial arrhythmia recurrences electrocardiographically documented during 1-year follow-up. The main safety objective is the incidence of endoscopically detected esophageal thermal lesions (EDEL). This trial includes a substudy of incidence of asymptomatic cerebral lesions detected by magnetic resonance imaging (MRI) after ablation. RESULTS A randomized clinical trial compares for the first time high-power short-duration and conventional ablation in order to obtain data about the efficacy and safety of the high-power technique in an adequate methodological context. CONCLUSIONS The results of the POWER FAST III could support the use of the high-power short-duration ablation in clinical practice. REGISTRATION ClinicalTrials.gov: NTC04153747.
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Affiliation(s)
- Sergio Castrejón-Castrejón
- Arrhythmia & Robotic EP Unit, Cardiology Department, Hospital Universitario La Paz-IdiPaz, Madrid, Spain
| | - Marcel Martínez Cossiani
- Arrhythmia & Robotic EP Unit, Cardiology Department, Hospital Universitario La Paz-IdiPaz, Madrid, Spain
| | - Miguel Jáuregui-Abularach
- Arrhythmia & Robotic EP Unit, Cardiology Department, Hospital Universitario La Paz-IdiPaz, Madrid, Spain
| | - Nuria Basterra Sola
- Cardiology Department, Complejo Hospitalario de Navarra-IdiSNA (Navarra Institute for Health Research), Pamplona, Spain
| | - José Luis Ibáñez Criado
- Cardiology Department, Hospital General Universitario de Alicante-ISABIAL (Instituto de Investigación Sanitaria Y Biomédica de Alicante), Alicante, Spain
| | | | - Ivo Roca Luque
- Cardiology Department, Hospital Clínic, Barcelona, Spain
| | | | | | | | | | | | | | | | - Nerea Gonzalo Bada
- Acute Care Unit, Department of Gastroenterology, Hospital Universitario La Paz-IdiPaz, Madrid, Spain
| | | | - Leonardo Elías Guido López
- Arrhythmia & Robotic EP Unit, Cardiology Department, Hospital Universitario La Paz-IdiPaz, Madrid, Spain
| | | | - Daniel Merino
- Arrhythmia & Robotic EP Unit, Cardiology Department, Hospital Universitario La Paz-IdiPaz, Madrid, Spain
| | - Carlos Escobar Cervantes
- Arrhythmia & Robotic EP Unit, Cardiology Department, Hospital Universitario La Paz-IdiPaz, Madrid, Spain
| | - José Luis Merino
- Arrhythmia & Robotic EP Unit, Cardiology Department, Hospital Universitario La Paz-IdiPaz, Madrid, Spain.
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9
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Steiger N, Qian PC, Foley G, Bomma T, Kreidieh O, Whitaker J, Thurber CJ, Koplan BA, Tadros TM, Kapur S, Zei PC, Tedrow UB, Romero J, Sauer WH. Measured temperatures using uninterrupted and interrupted sequences of radiofrequency applications in a phantom gel model: implications for esophageal injury. J Interv Card Electrophysiol 2023; 66:1925-1928. [PMID: 36114382 DOI: 10.1007/s10840-022-01373-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/12/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Nathaniel Steiger
- Cardiac Arrhythmia Service, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA.
| | - Pierre C Qian
- Westmead Hospital and the University of Sydney, Sydney, Australia
| | - Grace Foley
- University of Massachusetts, Lowell and Amherst, Amherst, MA, USA
| | - Tarun Bomma
- University of Massachusetts, Lowell and Amherst, Amherst, MA, USA
| | - Omar Kreidieh
- Cardiac Arrhythmia Service, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - John Whitaker
- Cardiac Arrhythmia Service, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Clinton J Thurber
- Cardiac Arrhythmia Service, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Bruce A Koplan
- Cardiac Arrhythmia Service, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Thomas M Tadros
- Cardiac Arrhythmia Service, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Sunil Kapur
- Cardiac Arrhythmia Service, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Paul C Zei
- Cardiac Arrhythmia Service, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Usha B Tedrow
- Cardiac Arrhythmia Service, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Jorge Romero
- Cardiac Arrhythmia Service, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - William H Sauer
- Cardiac Arrhythmia Service, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
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10
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Dhawan R, DeSimone CV. Strategies to mitigate heating during radiofrequency ablation for atrial fibrillation. J Interv Card Electrophysiol 2023; 66:1769-1771. [PMID: 36495413 DOI: 10.1007/s10840-022-01443-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Rahul Dhawan
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Christopher V DeSimone
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, 55905, USA.
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11
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Nakatani Y, Sudo T, Suzuki J, Take Y, Takizawa R, Yoshimura S, Naito S. Cryoballoon ablation for atrial fibrillation in a patient with esophageal dilatation due to achalasia. HeartRhythm Case Rep 2023; 9:461-464. [PMID: 37492040 PMCID: PMC10363462 DOI: 10.1016/j.hrcr.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Affiliation(s)
- Yosuke Nakatani
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Toshinaga Sudo
- Division of Gastroenterological Surgery, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Junko Suzuki
- Division of Gastroenterological Surgery, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Yutaka Take
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Ryoya Takizawa
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Shingo Yoshimura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
| | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center, Gunma, Japan
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12
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Yamaguchi J, Takigawa M, Goya M, Martin CA, Yamamoto T, Ikenouchi T, Shigeta T, Nishimura T, Tao S, Miyazaki S, Sasano T. Comparison of three different approaches to very high-power short-duration ablation using the QDOT-MICRO catheter. J Cardiovasc Electrophysiol 2023; 34:888-897. [PMID: 36852902 DOI: 10.1111/jce.15875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/31/2023] [Accepted: 02/20/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND/OBJECTIVES The QDOT-MICRO™ catheter allows very high-power and short-duration (vHPSD) ablation. This study aimed to investigate lesion characteristics using different ablation settings. METHODS Radiofrequency applications (90 W/4 s, temperature-control mode with 55°C or 60°C target) were performed in excised porcine myocardium using three different approaches: single (SA), double nonrepetitive (DNRA), and double repetitive applications (DRA). Applications were performed with an interval of 1 min for DNRA, and without interval for DRA. RESULTS A total of 480 lesions were analyzed. Lesion depth and volume were largest for DRA followed by DNRA and SA regardless of catheter direction (depth: 3.8 vs. 3.3 vs. 2.6 mm, p < .001 for all comparisons; volume: 176.6 vs. 145.1 vs. 97.0 mm3 , p < .001 for all comparisons). Surface area was significantly larger for DRA than for SA (45.1 vs. 38.3 mm2 , p < .001) and larger for DNRA than for SA (44.5 vs. 38.3 mm2 , p < .001), but was similar between DRA and DNRA (45.1 vs. 44.5 mm2 , p = .54). Steam-pops more frequently occurred for DRA than for SA (15.6% vs. 4.4%, p = .004) and DNRA (15.6% vs. 6.9%, p = .061), but the incidence was similar between SA and DNRA (4.4% vs. 6.9%, p = 1). Although surface area and lesion volume were larger in lesions with steam-pops than without steam-pops (46.5 vs. 38.1 mm2 , p = .018 and 128.3 vs. 96.8 mm3 , p = .068, respectively), lesions were not deeper (pop(+): 2.5 mm vs. pop(-): 2.6 mm, p = .75). CONCLUSIONS DNRA produces larger lesions than SA without increasing the risk of steam-pops. DRA produces the largest lesions among the three groups, but with an increased risk of steam-pops. Even with steam-pops, lesions do not become deeper in vHPSD ablation.
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Affiliation(s)
- Junji Yamaguchi
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University Hospital, Tokyo, Japan.,Department of Clinical and Diagnostic Laboratory Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masateru Takigawa
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Claire A Martin
- Royal Papworth Hospital NHS Foundation Trust and Cambridge University, Cambridge, UK
| | - Tasuku Yamamoto
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Takashi Ikenouchi
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Takatoshi Shigeta
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Takuro Nishimura
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Susumu Tao
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Shinsuke Miyazaki
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University Hospital, Tokyo, Japan
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13
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Kaul R, Barbhaiya CR. Hotter? Yes. Faster? Yes. Better? Maybe. J Cardiovasc Electrophysiol 2023; 34:379-381. [PMID: 36525459 DOI: 10.1111/jce.15783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/11/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Risheek Kaul
- Leon H. Charney Division of Cardiology, New York University Langone Health, New York, New York, USA
| | - Chirag R Barbhaiya
- Leon H. Charney Division of Cardiology, New York University Langone Health, New York, New York, USA
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14
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Jin S, Lin W, Fang X, Liao H, Zhan X, Fu L, Jiang J, Ye X, Liu H, Chen Y, Pu S, Wu S, Deng H, Xue Y. High-Power, Short-Duration Ablation under the Guidance of Relatively Low Ablation Index Values for Paroxysmal Atrial Fibrillation: Long-Term Outcomes and Characteristics of Recurrent Atrial Arrhythmias. J Clin Med 2023; 12:jcm12030971. [PMID: 36769620 PMCID: PMC9917927 DOI: 10.3390/jcm12030971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE The purpose of this study was to evaluate the difference in effectiveness and safety of high-power, short-duration (HPSD) radiofrequency catheter ablation (RFA) guided by relatively low ablation index (AI) values and conventional RFA in paroxysmal atrial fibrillation (PAF) patients. METHODS The HPSD RFA strategy (40-50 W, AI 350-400 for anterior, 320-350 for posterior wall; n = 547) was compared with the conventional RFA strategy (25-40 W, without AI; n = 396) in PAF patients who underwent their first ablation. Propensity-score matching analyses were used to compare the outcomes of the two groups while controlling for confounders. RESULTS After using propensity-score matching analysis, the HPSD group showed a higher early recurrence rate (22.727% vs. 13.636%, p = 0.003), similar late recurrence rate, and comparable safety (p = 0.604) compared with the conventional group. For late recurrent atrial arrhythmia types, the rate of regular atrial tachycardia was significantly higher in the HPSD group (p = 0.013). Additionally, the rate of chronic pulmonary vein reconnection and non-pulmonary vein triggers during repeat procedures was similar in both groups. CONCLUSIONS For PAF patients, compared with the conventional RFA strategy, the HPSD RFA strategy at relatively low AI settings had a higher early recurrence rate, similar long-term success rate, and comparable safety.
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Affiliation(s)
- Shuyu Jin
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510515, China
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Weidong Lin
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Xianhong Fang
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Hongtao Liao
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Xianzhang Zhan
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Lu Fu
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Junrong Jiang
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Xingdong Ye
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Huiyi Liu
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Yanlin Chen
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Sijia Pu
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- School of Medicine, South China University of Technology, Guangzhou 510006, China
| | - Shulin Wu
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Hai Deng
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510515, China
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Correspondence: (H.D.); (Y.X.)
| | - Yumei Xue
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou 510515, China
- Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Correspondence: (H.D.); (Y.X.)
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15
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Pérez JJ, Berjano E, González-Suárez A. How far the zone of heat-induced transient block extends beyond the lesion during RF catheter cardiac ablation. Int J Hyperthermia 2023; 40:2163310. [PMID: 36592987 DOI: 10.1080/02656736.2022.2163310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
PURPOSE While radiofrequency catheter ablation (RFCA) creates a lesion consisting of the tissue points subjected to lethal heating, the sublethal heating (SH) undergone by the surrounding tissue can cause transient electrophysiological block. The size of the zone of heat-induced transient block (HiTB) has not been quantified to date. Our objective was to use computer modeling to provide an initial estimate. METHODS AND MATERIALS We used previous experimental data together with the Arrhenius damage index (Ω) to fix the Ω values that delineate this zone: a lower limit of 0.1-0.4 and upper limit of 1.0 (lesion boundary). An RFCA computer model was used with different power-duration settings, catheter positions and electrode insertion depths, together with dispersion of the tissue's electrical and thermal characteristics. RESULTS The HiTB zone extends in depth to a minimum and maximum distance of 0.5 mm and 2 mm beyond the lesion limit, respectively, while its maximum width varies with the energy delivered, extending to a minimum of 0.6 mm and a maximum of 2.5 mm beyond the lesion, reaching 3.5 mm when high energy settings are used (25 W-20s, 500 J). The dispersion of the tissue's thermal and electrical characteristics affects the size of the HiTB zone by ±0.3 mm in depth and ±0.5 mm in maximum width. CONCLUSIONS Our results suggest that the size of the zone of heat-induced transient block during RFCA could extend beyond the lesion limit by a maximum of 2 mm in depth and approximately 2.5 mm in width.
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Affiliation(s)
- Juan J Pérez
- BioMIT, Department of Electronic Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Enrique Berjano
- BioMIT, Department of Electronic Engineering, Universitat Politècnica de València, Valencia, Spain
| | - Ana González-Suárez
- School of Engineering, University of Galway, Galway, Ireland.,Translational Medical Device Lab, University of Galway, Galway, Ireland
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16
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Otsuka N, Okumura Y, Kuorkawa S, Nagashima K, Wakamatsu Y, Hayashida S, Ohkubo K, Nakai T, Hao H, Takahashi R, Taniguchi Y. In vivo tissue temperature during lesion size index-guided 50W ablation versus 30W ablation: A porcine study. J Cardiovasc Electrophysiol 2023; 34:108-116. [PMID: 36300696 DOI: 10.1111/jce.15722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/21/2022] [Accepted: 10/17/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Neither the actual in vivo tissue temperatures reached with lesion size index (LSI)-guided high-power short-duration (HPSD) ablation for atrial fibrillation nor the safety profile has been elucidated. METHODS We conducted a porcine study (n = 7) in which, after right thoracotomy, we implanted 6-8 thermocouples epicardially in the superior vena cava, right pulmonary vein, and esophagus close to the inferior vena cava. We compared tissue temperatures reached during 50 W-HPSD ablation with those reached during standard (30 W) ablation, both targeting an LSI of 5.0 (5-15 g contact force). RESULTS Tmax (maximum tissue temperature when the thermocouple was located ≤5 mm from the catheter tip) reached during HPSD ablation was modestly higher than that reached during standard ablation (58.0 ± 10.1°C vs. 53.6 ± 9.2°C; p = .14) and peak tissue temperature correlated inversely with the distance between the catheter tip and the thermocouple, regardless of the power settings (HPSD: r = -0.63; standard: r = -0.66). Lethal temperature (≥50°C) reached 6.3 ± 1.8 s and 16.9 ± 16.1 s after the start of HPSD and standard ablation, respectively (p = .002), and it was best predicted at a catheter tip-to-thermocouple distance cut point of 2.8 and 5.3 mm, respectively. All lesions produced by HPSD ablation and by standard ablation were transmural. There was no difference between HPSD ablation and standard ablation in the esophageal injury rate (70% vs. 75%, p = .81), but the maximum distance from the esophageal adventitia to the injury site tended to be shorter (0.94 ± 0.29 mm vs. 1.40 ± 0.57 mm, respectively; p = .09). CONCLUSIONS Actual tissue temperatures reached with LSI-guided HPSD ablation appear to be modestly higher, with a shorter distance between the catheter tip and thermocouple achieving lethal temperature, than those reached with standard ablation. HPSD ablation lasting <6 s may help minimize lethal thermal injury to the esophagus lying at a close distance.
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Affiliation(s)
- Naoto Otsuka
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, Tokyo, Japan
| | - Yasuo Okumura
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, Tokyo, Japan
| | - Sayaka Kuorkawa
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, Tokyo, Japan
| | - Koichi Nagashima
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, Tokyo, Japan
| | - Yuji Wakamatsu
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, Tokyo, Japan
| | - Satoshi Hayashida
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, Tokyo, Japan
| | - Kimie Ohkubo
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, Tokyo, Japan
| | - Toshiko Nakai
- Department of Medicine, Division of Cardiology, Nihon University School of Medicine, Tokyo, Japan
| | - Hiroyuki Hao
- Department of Pathology and Microbiology, Division of Human Pathology, Nihon University School of Medicine, Tokyo, Japan
| | - Rie Takahashi
- Section of Laboratory for Animal Experiments, Institute of Medical Science, Medical Research Support Center, Nihon University School of Medicine, Tokyo, Japan
| | - Yoshiki Taniguchi
- Section of Laboratory for Animal Experiments, Institute of Medical Science, Medical Research Support Center, Nihon University School of Medicine, Tokyo, Japan
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17
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Chinitz JS, Harris EQ. Mitigating Esophageal Injury after Atrial Fibrillation Ablation Guided by Ablation Index; CLOSEr to goal. J Cardiovasc Electrophysiol 2022; 33:2285-2287. [PMID: 35979648 DOI: 10.1111/jce.15655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 08/10/2022] [Indexed: 11/27/2022]
Abstract
In the ongoing quest to optimize outcomes for atrial fibrillation ablation, efforts continue to balance the reliable creation of durable transmural ablation lesions, while minimizing risk to neighboring sensitive structures. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jason S Chinitz
- South Shore University Hospital, Northwell Health, Bay Shore, NY
| | - Eli Q Harris
- Nassau University Medical Center, East Meadow, NY
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18
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Grosse Meininghaus D, Freund R, Kleemann T, Christoph Geller J. Calculated parameters of luminal esophageal temperatures predict esophageal injury following conventional and high-power short-duration radiofrequency pulmonary vein isolation. J Cardiovasc Electrophysiol 2022; 33:1167-1176. [PMID: 35445476 DOI: 10.1111/jce.15509] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/11/2022] [Accepted: 04/19/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Luminal esophageal temperature (LET) monitoring is not associated with reduced esophageal injury following pulmonary vein isolation (PVI). OBJECTIVE Detailed analysis of (the temporal and spatial gradients of) LET measurements may better predict the risk for esophageal injury. METHODS Between January 2020 and December 2021, LET maxima, duration of LET rise above baseline, and area under the LET curve (AUC) were calculated offline and correlated with (endoscopy and endoscopic ultrasound detected) esophageal injury (i.e., mucosal esophageal lesions [ELs], periesophageal edema, and gastric motility disorders) following PVI using moderate-power moderate-duration (MPMD [25-30 W/25-30s]) and high-power short-duration (HPSD [50 W/13s]) radiofrequency (RF) settings. RESULTS 63 patients (69 ± 9 years old, 32 male, 51 MPMD and 12 HPSD) were studied. The esophageal injury was frequent (40% in both groups), mucosal ELs were more common with MPMD, and edema was frequently observed following HPSD. RF-duration, total RF-energy at the left atrial (LA) posterior wall, and distance between LA and esophagus were not different between patients with/without esophageal injury. In contrast, to LET and LET duration above baseline, AUC was the best predictor and significantly increased in patients with esophageal injury (3422 vs. 2444 K. s). CONCLUSION For both ablation strategies, AUC of the LET curves best predicted esophageal injury. HPSD is associated with similar rates of esophageal injury when (mostly subclinical) periesophageal alterations (that are of unclear clinical relevance) are included. Whether integration of these calculated LET parameters is useful to prevent esophageal injury remains to be seen.
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Affiliation(s)
| | - Robert Freund
- Thiem Research, Carl-Thiem-Hospital, Cottbus, Germany
| | - Tobias Kleemann
- Department of Gastroenterology, Carl-Thiem-Hospital, Cottbus, Germany
| | - J Christoph Geller
- Division of Cardiology, Arrhythmia Section, Zentralklinik Bad Berka, Bad Berka, Germany.,Otto-von-Guericke University School of Medicine, Magdeburg, Germany
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19
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Nakatani Y, Nuñez-Garcia M, Cheniti G, Sridi-Cheniti S, Bustin A, Jia S, Goujeau C, André C, Nakashima T, Krisai P, Takagi T, Kamakura T, Derval N, Duchateau J, Pambrun T, Chauvel R, Sacher F, Hocini M, Haïssaguerre M, Sermesant M, Jais P, Cochet H. Preoperative Personalization of Atrial Fibrillation Ablation Strategy to Prevent Esophageal Injury: Impact of Changes in Esophageal Position. J Cardiovasc Electrophysiol 2022; 33:908-916. [PMID: 35274776 DOI: 10.1111/jce.15447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/12/2022] [Accepted: 02/16/2022] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Due to changes in esophageal position, preoperative assessment of the esophageal location may not mitigate the risk of esophageal injury in catheter ablation for atrial fibrillation (AF). This study aimed to assess esophageal motion and its impact on AF ablation strategies. METHODS AND RESULTS Ninety-seven AF patients underwent 2 computed tomography (CT) scans. The area at risk of esophageal injury (AAR) was defined as the left atrial surface ≤3 mm from the esophagus. On CT1, ablation lines were drawn blinded to the esophageal location to create 3 ablation sets: individual pulmonary vein isolation (PVI), wide antral circumferential ablation (WACA), and WACA with linear ablation (WACA+L). Thereafter, ablation lines for WACA and WACA+L were personalized to avoid the AAR. Rigid registration was performed to align CT1 onto CT2, and the relationship between ablation lines and the AAR on CT2 was analyzed. The esophagus moved by 3.6 [2.7 to 5.5] mm. The AAR on CT2 was 8.6 ± 3.3 cm2 , with 77% overlapping that on CT1. High body mass index was associated with the AAR mismatch (standardized β 0.382, P <0.001). Without personalization, AARs on ablation lines for individual PVI, WACA, and WACA+L were 0 [0-0.4], 0.8 [0.5-1.2], 1.7 [1.2-2.0] cm2 . Despite the esophageal position change, the personalization of ablation lines for WACA and WACA+L reduced the AAR on lines to 0 [0-0.5] and 0.7 [0.3-1.0] cm2 (P <0.001 for both). CONCLUSION The personalization of ablation lines based on a preoperative CT reduced ablation to the AAR despite changes in esophageal position. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Yosuke Nakatani
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Pessac, France
| | - Marta Nuñez-Garcia
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France.,Université de Bordeaux, Bordeaux, France
| | - Ghassen Cheniti
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Pessac, France
| | - Soumaya Sridi-Cheniti
- Department of Cardiovascular Imaging, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Pessac, France
| | - Aurélien Bustin
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France.,Université de Bordeaux, Bordeaux, France
| | - Shuman Jia
- INRIA Epione research team, Sophia Antipolis, France
| | - Cyril Goujeau
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Pessac, France
| | - Clementine André
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Pessac, France
| | - Takashi Nakashima
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Pessac, France
| | - Philipp Krisai
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Pessac, France
| | - Takamitsu Takagi
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Pessac, France
| | - Tsukasa Kamakura
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Pessac, France
| | - Nicolas Derval
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France.,Université de Bordeaux, Bordeaux, France
| | - Josselin Duchateau
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France.,Université de Bordeaux, Bordeaux, France
| | - Thomas Pambrun
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France.,Université de Bordeaux, Bordeaux, France
| | - Remi Chauvel
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France.,Université de Bordeaux, Bordeaux, France
| | - Frederic Sacher
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France.,Université de Bordeaux, Bordeaux, France
| | - Mélèze Hocini
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France.,Université de Bordeaux, Bordeaux, France
| | - Michel Haïssaguerre
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France.,Université de Bordeaux, Bordeaux, France
| | - Maxime Sermesant
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France.,INRIA Epione research team, Sophia Antipolis, France
| | - Pierre Jais
- Department of Cardiac Pacing and Electrophysiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Pessac, France.,IHU Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France.,Université de Bordeaux, Bordeaux, France
| | - Hubert Cochet
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France.,Université de Bordeaux, Bordeaux, France.,Department of Cardiovascular Imaging, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Pessac, France
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20
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Tomlinson DR, Mandrola J. Radiofrequency ablation data associated with atrioesophageal fistula. HeartRhythm Case Rep 2022; 7:781-790. [PMID: 34987959 PMCID: PMC8695297 DOI: 10.1016/j.hrcr.2021.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- David R. Tomlinson
- University Hospitals Plymouth NHS Trust, South West Cardiothoracic Centre, Derriford Hospital, Plymouth, United Kingdom
- Address reprint requests and correspondence: David R. Tomlinson, University Hospitals Plymouth NHS Trust, South West Cardiothoracic Centre, Derriford Hospital, Derriford Rd, Plymouth, PL6 8DH, UK.
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21
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Leung LWM, Akhtar Z, Sheppard MN, Louis-Auguste J, Hayat J, Gallagher MM. Preventing esophageal complications from atrial fibrillation ablation: A review. Heart Rhythm O2 2022; 2:651-664. [PMID: 34988511 PMCID: PMC8703125 DOI: 10.1016/j.hroo.2021.09.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Atrioesophageal fistula is a life-threatening complication of ablation treatment for atrial fibrillation. Methods to reduce the risk of esophageal injury have evolved over the last decade, and diagnosis of this complication remains difficult and therefore challenging to treat in a timely manner. Delayed diagnosis leads to treatment occurring in the context of a critically ill patient, contributing to the poor prognosis associated with this complication. The associated mortality risk can be as high as 70%. Recent important advances in preventative techniques are explored in this review. Preventative techniques used in current clinical practice are discussed, which include high-power short-duration ablation, esophageal temperature probe monitoring, cryotherapy and laser balloon technologies, and use of proton pump inhibitors. A lack of randomized clinical evidence for the effectiveness of these practical methods are found. Alternative methods of esophageal protection has emerged in recent years, including mechanical deviation of the esophagus and esophageal temperature control (esophageal cooling). Although these are fairly recent methods, we discuss the available evidence to date. Mechanical deviation of the esophagus is due to undergo its first randomized study. Recent randomized study on esophageal cooling has shown promise of its effectiveness in preventing thermal injuries. Lastly, novel ablation technology that may be the future of esophageal protection, pulsed field ablation, is discussed. The findings of this review suggest that more robust clinical evidence for esophageal protection methods is warranted to improve the safety of atrial fibrillation ablation.
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Affiliation(s)
- Lisa W M Leung
- Department of Cardiology, St George's Hospital NHS Foundation Trust, London, United Kingdom
| | - Zaki Akhtar
- Department of Cardiology, St George's Hospital NHS Foundation Trust, London, United Kingdom
| | - Mary N Sheppard
- Cardiac Pathology Unit, St. George's University of London, London, United Kingdom
| | - John Louis-Auguste
- Department of Gastroenterology, St George's Hospital NHS Foundation Trust, London, United Kingdom
| | - Jamal Hayat
- Department of Gastroenterology, St George's Hospital NHS Foundation Trust, London, United Kingdom
| | - Mark M Gallagher
- Department of Cardiology, St George's Hospital NHS Foundation Trust, London, United Kingdom
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22
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Esophageal temperature during atrial fibrillation ablation poorly predicts esophageal injury: An observational study. Heart Rhythm O2 2022; 2:570-577. [PMID: 34988501 PMCID: PMC8703177 DOI: 10.1016/j.hroo.2021.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Esophageal injury (EI) remains a concern when performing pulmonary vein isolation (PVI) using the high-power short-duration (HPSD) technique. Objective We aim to indicate that high esophageal temperature during HPSD PVI does not correlate with positive esophageal endoscopy (EGD) findings. Methods A retrospective observational study was performed on 43 patients undergoing PVI using HPSD (50 W for 6–7 seconds per lesion) at Tulane Medical Center from July 2020 to January 2021. Esophageal temperature was monitored throughout the procedure using a temperature probe and patients underwent EGD the following day. Small ulcers, nonbleeding erosions, erythema, and/or esophagitis were considered positive EGD findings. Results Mean age was 64.9 years; 46.5% of the patients were female. Eleven patients had positive EGD findings (group 1) and 32 patients had normal EGD (group 2). There was no statistical difference in mean esophageal peak temperature between group 1 and group 2 (43.9°C ± 2.9°C and 42.5°C ± 2.3°C, respectively, P = .17). There was no association between positive EGD results and esophageal temperature during PVI. Mean baseline esophageal temperature was similar in both groups (36.1°C, P = .78). Average contact force (P = .53), ablation time (P = .67), age (P = .3096), sex (P = .4), body mass index (P = .14), and other comorbidities did not correlate with positive endoscopy results. We found positive correlation between the distance of the left atrium (LA) to esophagus and positive EGD (P = .0001). Conclusion EI during HPSD PVI does not correlate to esophageal temperature changes during ablation. However, esophageal injury does correlate to a shorter proximity of the esophagus to the LA.
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23
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Montoya MM, Bustamante TG, Berjano E, Mickelsen SR, Daniels JD, Arango PH, Schieber J, Kulstad E. Proactive esophageal cooling protects against thermal insults during high-power short-duration radiofrequency cardiac ablation. Int J Hyperthermia 2022; 39:1202-1212. [PMID: 36104029 PMCID: PMC9771690 DOI: 10.1080/02656736.2022.2121860] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Proactive cooling with a novel cooling device has been shown to reduce endoscopically identified thermal injury during radiofrequency (RF) ablation for the treatment of atrial fibrillation using medium power settings. We aimed to evaluate the effects of proactive cooling during high-power short-duration (HPSD) ablation. METHODS A computer model accounting for the left atrium (1.5 mm thickness) and esophagus including the active cooling device was created. We used the Arrhenius equation to estimate the esophageal thermal damage during 50 W/ 10 s and 90 W/ 4 s RF ablations. RESULTS With proactive esophageal cooling in place, temperatures in the esophageal tissue were significantly reduced from control conditions without cooling, and the resulting percentage of damage to the esophageal wall was reduced around 50%, restricting damage to the epi-esophageal region and consequently sparing the remainder of the esophageal tissue, including the mucosal surface. Lesions in the atrial wall remained transmural despite cooling, and maximum width barely changed (<0.8 mm). CONCLUSIONS Proactive esophageal cooling significantly reduces temperatures and the resulting fraction of damage in the esophagus during HPSD ablation. These findings offer a mechanistic rationale explaining the high degree of safety encountered to date using proactive esophageal cooling, and further underscore the fact that temperature monitoring is inadequate to avoid thermal damage to the esophagus.
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Affiliation(s)
| | | | - Enrique Berjano
- BioMIT, Department of Electronic Engineering, Universitat Politècnica de València, Spain
| | | | - James D. Daniels
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Jay Schieber
- Illinois Institute of Technology, Chicago, IL, USA
| | - Erik Kulstad
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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24
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Procedural time reduction associated with active esophageal cooling during pulmonary vein isolation. J Interv Card Electrophysiol 2022; 65:617-623. [PMID: 35416632 PMCID: PMC9726815 DOI: 10.1007/s10840-022-01204-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/28/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Active esophageal cooling is increasingly utilized as an alternative to luminal esophageal temperature (LET) monitoring for protection against thermal injury during pulmonary vein isolation (PVI) when treating atrial fibrillation (AF). Published data demonstrate the efficacy of active cooling in reducing thermal injury, but impacts on procedural efficiency are not as well characterized. LET monitoring compels pauses in ablation due to heat stacking and temperature overheating alarms that in turn delay progress of the PVI procedure, whereas active esophageal cooling allows avoidance of this phenomenon. Our objective was to measure the change in PVI procedure duration after implementation of active esophageal cooling as a protective measure against esophageal injury. METHODS We performed a retrospective review under IRB approval of patients with AF undergoing PVI between January 2018 and February 2020. For each patient, we recorded age, gender, and total procedure time. We then compared procedure times before and after the implementation of active esophageal cooling as a replacement for LET monitoring. RESULTS A total of 373 patients received PVI over the study period. LET monitoring using a multi-sensor probe was performed in 198 patients, and active esophageal cooling using a dedicated device was performed in 175 patients. Patient characteristics did not significantly differ between groups (mean age of 67 years, and gender 37.4% female). Mean procedure time was 146 ± 51 min in the LET-monitored patients, and 110 ± 39 min in the actively cooled patients, representing a reduction of 36 min, or 24.7% of total procedure time (p < .001). Median procedure time was 141 [IQR 104 to 174] min in the LET-monitored patients and 100 [IQR 84 to 122] min in the actively cooled patients, for a reduction of 41 min, or 29.1% of total procedure time (p < .001). CONCLUSIONS Implementation of active esophageal cooling for protection against esophageal injury during PVI was associated with a significantly large reduction in procedure duration.
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25
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Pérez JJ, González-Suárez A, Maher T, Nakagawa H, d'Avila A, Berjano E. Relationship between luminal esophageal temperature and volume of esophageal injury during RF ablation: In silico study comparing low power-moderate duration vs. high power-short duration. J Cardiovasc Electrophysiol 2021; 33:220-230. [PMID: 34855276 DOI: 10.1111/jce.15311] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/09/2021] [Accepted: 10/25/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To model the evolution of peak temperature and volume of damaged esophagus during and after radiofrequency (RF) ablation using low power-moderate duration (LPMD) versus high power-short duration (HPSD) or very high power-very short duration (VHPVSD) settings. METHODS An in silico simulation model of RF ablation accounting for left atrial wall thickness, nearby organs and tissues, as well as catheter contact force. The model used the Arrhenius equation to derive a thermal damage model and estimate the volume of esophageal damage over time during and after RF application under conditions of LPMD (30 W, 20 s), HPSD (50 W, 6 s), and VHPVSD (90 W, 4 s). RESULTS There was a close correlation between maximum peak temperature after RF application and volume of esophageal damage, with highest correlation (R2 = 0.97) and highest volume of esophageal injury in the LPMD group. A greater increase in peak temperature and greater relative increase in esophageal injury volume in the HPSD (240%) and VHPSD (270%) simulations occurred after RF termination. Increased endocardial to esophageal thickness was associated with a longer time to maximum peak temperature (R2 > 0.92), especially in the HPSD/VHPVSD simulations, and no esophageal injury was seen when the distances were >4.5 mm for LPMD or >3.5 mm for HPSD. CONCLUSION LPMD is associated with a larger total volume of esophageal damage due to the greater total RF energy delivery. HPSD and VHPVSD shows significant thermal latency (resulting from conductive tissue heating after RF termination), suggesting a requirement for fewer esophageal temperature cutoffs during ablation.
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Affiliation(s)
- Juan J Pérez
- Department of Electronic Engineering, BioMIT, Universitat Politècnica de València, Valencia, Spain
| | - Ana González-Suárez
- Electrical and Electronic Engineering Department, National University of Ireland Galway, Galway, Ireland.,Translational Medical Device Lab, National University of Ireland Galway, Galway, Ireland
| | - Timothy Maher
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Hiroshi Nakagawa
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Andre d'Avila
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Enrique Berjano
- Department of Electronic Engineering, BioMIT, Universitat Politècnica de València, Valencia, Spain
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26
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Yavin HD, Bubar ZP, Higuchi K, Sroubek J, Kanj M, Cantillon D, Saliba WI, Tarakji KG, Hussein AA, Wazni O, Anter E. Impact of High-Power Short-Duration Radiofrequency Ablation on Esophageal Temperature Dynamic. Circ Arrhythm Electrophysiol 2021; 14:e010205. [PMID: 34706551 DOI: 10.1161/circep.121.010205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND High-power short-duration (HP-SD) radiofrequency ablation (RFA) has been proposed as a method for producing rapid and effective lesions for pulmonary vein isolation. The underlying hypothesis assumes an increased resistive heating phase and decreased conductive heating phase, potentially reducing the risk for esophageal thermal injury. The objective of this study was to compare the esophageal temperature dynamic profile between HP-SD and moderate-power moderate-duration (MP-MD) RFA ablation strategies. METHODS In patients undergoing pulmonary vein isolation, RFA juxtaposed to the esophagus was delivered in an alternate sequence of HP-SD (50 W, 8-10 s) and MP-MD (25 W, 15-20 s) between adjacent applications (distance, ≤4 mm). Esophageal temperature was recorded using a multisensor probe (CIRCA S-CATH). Temperature data included magnitude of temperature rise, maximal temperature, time to maximal temperature, and time return to baseline. In swine, a similar experimental design compared the effect of HP-SD and MP-MD on patterns of esophageal injury. RESULTS In 20 patients (68.9±5.8 years old; 60% persistent atrial fibrillation), 55 paired HP-SD and MP-MD applications were analyzed. The esophageal temperature dynamic profile was similar between HP-SD and MP-MD ablation strategies. Specifically, the magnitude of temperature rise (2.1 °C [1.4-3] versus 2.0 °C [1.5-3]; P=0.22), maximal temperature (38.4 °C [37.8-39.3] versus 38.5 °C [37.9-39.4]; P=0.17), time to maximal temperature (24.9±7.5 versus 26.3±6.8 s; P=0.1), and time of temperature to return to baseline (110±23.2 versus 111±25.1 s; P=0.86) were similar between HP-SD and MP-MD ablation strategies. In 6 swine, esophageal injury was qualitatively similar between HP-SD and MP-MD strategies. CONCLUSIONS Esophageal temperature dynamics are similar between HP-SD and MP-MD RFA strategies and result in comparable esophageal tissue injury. Therefore, when using a HP-SD RFA strategy, the shorter application duration should not prompt shorter intervals between applications.
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Affiliation(s)
- Hagai D Yavin
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, OH (H.D.Y., K.H., J.S., M.K., D.C., W.I.S., K.G.T., A.A.H., O.W., E.A.).,Mark-Josephson and Andrew Wit Research Laboratory, Department of Cardiovascular and Metabolic Sciences, Cleveland Clinic, Lerner Research Institute, OH (H.D.Y., Z.P.B., K.H., J.S., E.A.)
| | - Zachary P Bubar
- Mark-Josephson and Andrew Wit Research Laboratory, Department of Cardiovascular and Metabolic Sciences, Cleveland Clinic, Lerner Research Institute, OH (H.D.Y., Z.P.B., K.H., J.S., E.A.).,Biosense Webster of Johnson & Johnson, Irvine, CA (Z.P.B.)
| | - Koji Higuchi
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, OH (H.D.Y., K.H., J.S., M.K., D.C., W.I.S., K.G.T., A.A.H., O.W., E.A.).,Mark-Josephson and Andrew Wit Research Laboratory, Department of Cardiovascular and Metabolic Sciences, Cleveland Clinic, Lerner Research Institute, OH (H.D.Y., Z.P.B., K.H., J.S., E.A.)
| | - Jakub Sroubek
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, OH (H.D.Y., K.H., J.S., M.K., D.C., W.I.S., K.G.T., A.A.H., O.W., E.A.).,Mark-Josephson and Andrew Wit Research Laboratory, Department of Cardiovascular and Metabolic Sciences, Cleveland Clinic, Lerner Research Institute, OH (H.D.Y., Z.P.B., K.H., J.S., E.A.)
| | - Mohamed Kanj
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, OH (H.D.Y., K.H., J.S., M.K., D.C., W.I.S., K.G.T., A.A.H., O.W., E.A.)
| | - Daniel Cantillon
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, OH (H.D.Y., K.H., J.S., M.K., D.C., W.I.S., K.G.T., A.A.H., O.W., E.A.)
| | - Walid I Saliba
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, OH (H.D.Y., K.H., J.S., M.K., D.C., W.I.S., K.G.T., A.A.H., O.W., E.A.)
| | - Khaldoun G Tarakji
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, OH (H.D.Y., K.H., J.S., M.K., D.C., W.I.S., K.G.T., A.A.H., O.W., E.A.)
| | - Ayman A Hussein
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, OH (H.D.Y., K.H., J.S., M.K., D.C., W.I.S., K.G.T., A.A.H., O.W., E.A.)
| | - Oussama Wazni
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, OH (H.D.Y., K.H., J.S., M.K., D.C., W.I.S., K.G.T., A.A.H., O.W., E.A.)
| | - Elad Anter
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Cleveland Clinic, OH (H.D.Y., K.H., J.S., M.K., D.C., W.I.S., K.G.T., A.A.H., O.W., E.A.).,Mark-Josephson and Andrew Wit Research Laboratory, Department of Cardiovascular and Metabolic Sciences, Cleveland Clinic, Lerner Research Institute, OH (H.D.Y., Z.P.B., K.H., J.S., E.A.)
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Otsuka N, Okumura Y, Kuorkawa S, Nagashima K, Wakamatsu Y, Hayashida S, Ohkubo K, Nakai T, Hao H, Takahashi R, Taniguchi Y. Actual tissue temperature during ablation index-guided high-power short-duration ablation versus standard ablation: Implications in terms of the efficacy and safety of atrial fibrillation ablation. J Cardiovasc Electrophysiol 2021; 33:55-63. [PMID: 34713525 DOI: 10.1111/jce.15282] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/06/2021] [Accepted: 10/16/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Actual in vivo tissue temperatures and the safety profile during high-power short-duration (HPSD) ablation of atrial fibrillation have not been clarified. METHODS We conducted an animal study in which, after a right thoracotomy, we implanted 6-8 thermocouples epicardially in the superior vena cava, right pulmonary vein, and esophagus close to the inferior vena cava. We recorded tissue temperatures during a 50 W-HPSD ablation and 30 W-standard ablation targeting an ablation index (AI) of 400 (5-15 g contact force). RESULTS Maximum tissue temperatures reached with HSPD ablation were significantly higher than that reached with standard ablation (62.7 ± 12.5 vs. 52.7 ± 11.4°C, p = 0.033) and correlated inversely with the distance between the catheter tip and thermocouple, regardless of the power settings (HPSD: r = -0.71; standard: r = -0.64). Achievement of lethal temperatures (≥50°C) was within 7.6 ± 3.6 and 12.1 ± 4.1 s after HPSD and standard ablation, respectively (p = 0.003), and was best predicted at cutoff points of 5.2 and 4.4 mm, respectively. All HPSD ablation lesions were transmural, but 19.2% of the standard ablation lesions were not (p = 0.011). There was no difference between HPSD and standard ablation regarding the esophageal injury rate (30% vs. 33.3%, p > 0.99), with the injury appearing to be related to the short distance from the catheter tip. CONCLUSIONS Actual tissue temperatures reached with AI-guided HPSD ablation appeared to be higher with a greater distance between the catheter tip and target tissue than those with standard ablation. HPSD ablation for <7 s may help prevent collateral tissue injury when ablating within a close distance.
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Affiliation(s)
- Naoto Otsuka
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Sayaka Kuorkawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Koichi Nagashima
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yuji Wakamatsu
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Satoshi Hayashida
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Kimie Ohkubo
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Toshiko Nakai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hiroyuki Hao
- Division of Human Pathology, Department of Pathology and Microbiology, Nihon University School of Medicine, Tokyo, Japan
| | - Rie Takahashi
- Institute of Medical Science, Medical Research Support Center, Section of Laboratory for Animal Experiments, Nihon University School of Medicine, Tokyo, Japan
| | - Yoshiki Taniguchi
- Institute of Medical Science, Medical Research Support Center, Section of Laboratory for Animal Experiments, Nihon University School of Medicine, Tokyo, Japan
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Abstract
This article reviews and compares the rationale and evidence supporting high-power, short-duration radiofrequency (RF) ablation with those of conventional-power, conventional-duration RF ablation for atrial fibrillation (AF). The pros and cons of each approach, biophysics of ablation, pre-clinical studies informing clinical utilization, and the accumulated clinical evidence are presented. Both conventional-power, conventional-duration RF ablation and high-power, short-duration ablation are similarly safe, and effective approaches for AF ablation. Theoretical advantages of high-power, short-duration ablation, including greater procedure efficiency and limited conductive heating of collateral structures, must be weighed against the narrower safety margin related to rapid energy delivery during high power ablation.
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29
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[Pulmonary vein isolation using radiofrequency ablation]. Herzschrittmacherther Elektrophysiol 2021; 32:395-405. [PMID: 34309747 DOI: 10.1007/s00399-021-00794-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 06/29/2021] [Indexed: 10/20/2022]
Abstract
Catheter ablation represents the primary treatment for most arrhythmias. The effectiveness of catheter ablation for the treatment of atrial fibrillation is superior to drug therapy. Therefore, catheter ablation has been established as an increasingly common procedure in clinical routine. In this context, the electrical isolation of the pulmonary veins (PVI) constitutes the cornerstone of the interventional therapy of paroxysmal and persistent atrial fibrillation. This article describes the procedure of pulmonary vein isolation utilizing radiofrequency point-by-point ablation. It shall be a practical guide for the staff in the electrophysiological laboratory. This article continues a series of manuscripts focusing on interventional electrophysiology topics in the course of EP (electrophysiology) training.This article describes the procedure of pulmonary vein isolation utilizing radiofrequency point-by-point ablation. It shall be a practical guide for the staff in the electrophysiological laboratory. This article continues a series of manuscripts dealing with topics of interventional electrophysiology in the course of EP training.
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Khoshknab M, Kuo L, Zghaib T, Arkles J, Santangeli P, Marchlinski FE, Han Y, Desjardins B, Nazarian S. Esophageal luminal temperature rise during atrial fibrillation ablation is associated with lower radiofrequency electrode distance and baseline impedance. J Cardiovasc Electrophysiol 2021; 32:1857-1864. [PMID: 33993572 PMCID: PMC8256679 DOI: 10.1111/jce.15097] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/10/2021] [Accepted: 03/29/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Esophageal injury during atrial fibrillation (AF) ablation is a life-threatening complication. We sought to measure the association of esophageal temperature attenuation with radiofrequency (RF) electrode impedance, contact force, and distance from the esophagus. METHODS The retrospective study cohort included 35 patients with mean age 64 ± 10 years, of whom 74.3% were male, and 40% had persistent AF. All patients had undergone preprocedural cardiac magnetic resonance (CMR) followed by AF ablation with luminal esophageal temperature monitoring. Lesion locations were co-registered with CMR image segmentations of left atrial and esophageal anatomy. Luminal esophageal temperature, time matched RF lesion data, and ablation distance from the nearest esophageal location were collected as panel data. RESULTS Luminal esophageal temperature changes corresponding to 3667 distinct lesions, delivered with mean power 27.9 ± 5.5 W over a mean duration of 22.2 ± 10.5 s were analyzed. In multivariable analyses, clustered per patient, examining posterior wall lesions only, and adjusted for lesion power and duration as set by the operator, lesion distance from the esophagus (-0.003°C/mm, p < .001), and baseline impedance (-0.015°C/Ω, p < .001) were associated with changes in luminal esophageal temperature. CONCLUSION Esophageal luminal temperature rises are associated with shorter lesion distance from esophagus and lower baseline impedance during RF lesion delivery. When procedural strategy requires RF delivery near the esophagus, selection of sites with higher baseline impedance may improve safety.
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Affiliation(s)
- Mirmilad Khoshknab
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ling Kuo
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
- Division of Cardiology, Department of Internal Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Tarek Zghaib
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jeffrey Arkles
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Pasquale Santangeli
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Francis E. Marchlinski
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Yuchi Han
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Benoit Desjardins
- Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Saman Nazarian
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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Vassallo F, Meigre LL, Serpa E, Cunha CL, Carloni H, Simoes A, Amaral D, Lovatto C. Reduced esophageal heating in high-power short-duration atrial fibrillation ablation in the contact force catheter era. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1185-1192. [PMID: 34081339 DOI: 10.1111/pace.14286] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/13/2021] [Accepted: 05/30/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) ablation is alternative treatment to medical therapy. Most feared complication is atrioesophageal fistula METHODS: Observational, retrospective analysis of consecutive 355 patients undergoing first AF ablation. Low-power long-duration (LPLD) group contained 158 patients, with 121 (76.58%) having paroxysmal AF who underwent ablation with power 20/30W (anterior and posterior left atrial wall), 17 mL/min flow, and a contact force of 10-30 g for 30 s. High-power short-duration group (HPSD) contained 197 patients, with 113 (57.36%) having paroxysmal AF who underwent ablation at 45/50W of power with a contact force of 8-15 g/10-20 g and a 35 mL/min flow rate for 6-8 s on the anterior and the posterior left atrial wall, respectively. Both groups had pulmonary veins isolated and atrial flutter was ablated when needed. For patients not in sinus rhythm, cardioversion was performed before ablation RESULTS: There were no complications. LPLD group: Left atrial time 118.74 min, total 145.32 min, radiofrequency time 4317.99s, X-ray 13.42 min, and elevation of luminal esophageal temperature (LET) in 132 (84.53%) patients. HPSD group: Left atrial time 72.16 min, total 93.76 min, radiofrequency time 1511.29s, X-ray 7.6 min, and LET elevation in only 75 (38.07%) patients. A markedly higher rate of first-pass isolation was observed in HPSD compared to LPLD, 77.16% versus 13.29%, respectively. Recurrence occurred in 64 (40.50%) and 32 (16.24%) in 28.45 and 22.35 months in LPLD and HPSD patients, respectively. In LPLD, 10 patients were submitted to endoscopy, and one (10%) had mild erythema and in HPSD, 13 performed the endoscopy, with two (15.38%) patients showing mild erythema CONCLUSION: HPSD technique compared to the LPLD technique showed significant reduced radiofrequency and fluoroscopy times, higher rate of first-pass isolation, lower recurrence rate, and esophageal temperature elevation and may also have a protective effect avoiding incidental esophageal injury due to these findings.
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Affiliation(s)
- Fabricio Vassallo
- Department of Cardiology. Cardiology Institute of Espirito Santo.,Santa Rita of Cassia Hospital
| | | | - Eduardo Serpa
- Department of Cardiology. Cardiology Institute of Espirito Santo.,Santa Rita of Cassia Hospital
| | - Christiano Lemos Cunha
- Department of Cardiology. Cardiology Institute of Espirito Santo.,Santa Rita of Cassia Hospital
| | - Hermes Carloni
- Department of Cardiology. Cardiology Institute of Espirito Santo.,Santa Rita of Cassia Hospital
| | - Aloyr Simoes
- Department of Cardiology. Cardiology Institute of Espirito Santo.,Santa Rita of Cassia Hospital
| | | | - Carlos Lovatto
- Department of Cardiology. Cardiology Institute of Espirito Santo.,Santa Rita of Cassia Hospital
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Efficiency, Safety, and Efficacy of High-Power Short-Duration Radiofrequency Ablation in Patients with Atrial Fibrillation. Cardiol Res Pract 2021; 2021:8821467. [PMID: 33643666 PMCID: PMC7902128 DOI: 10.1155/2021/8821467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 12/14/2020] [Accepted: 12/19/2020] [Indexed: 11/18/2022] Open
Abstract
Pulmonary vein isolation (PVI) is the cornerstone therapy of atrial fibrillation (AF). Radiofrequency catheter ablation (RFCA) is performed using a point-by-point method to achieve durable PVI. However, this procedure remains complex and time-consuming, and the long-term clinical outcomes are still not satisfactory. Recently, there has been increasing interest in the clinical application of high-power short-duration (HPSD) approaches in the field of RFCA. HPSD ablation, distinguishing it from the conventional ablation strategy, delivers RF energy at a high power and saves the dwell time at each site. It is unknown whether the HPSD approach can bring some gratifying changes in the field of RF energy ablation. A number of experimental studies and clinical studies have been conducted regarding this topic. The review aimed to summarize the research findings and evaluate the procedural efficiency, safety, and clinical outcomes of the HPSD approach based on the evidence available to date.
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Houmsse M, Daoud EG. Protection of the esophagus during catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol 2021; 32:2824-2829. [PMID: 33556991 DOI: 10.1111/jce.14934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/06/2021] [Accepted: 01/11/2021] [Indexed: 12/27/2022]
Abstract
Esophageal injury still occurs with high frequency during ablation of atrial fibrillation (AF). The purpose of this study is to provide a review of methods to protect the esophagus from injury during AF ablation. Despite advances in imaging and ablation, the potential risk of esophageal injury during AF ablation remains an important concern with a high occurrence of esophageal injury (≈15%). There have been numerous studies evaluating varied techniques for esophageal protection including active cooling and displacement of the esophagus. These techniques are reviewed in this manuscript as well as the role of esophageal protection in managing patients undergoing AF ablation procedure.
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Affiliation(s)
- Mahmoud Houmsse
- Division of Cardiology, Department of Medicine, Richard M. Ross Heart Hospital, The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Emile G Daoud
- Division of Cardiology, Department of Medicine, Richard M. Ross Heart Hospital, The Ohio State University Medical Center, Columbus, Ohio, USA
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Grosse Meininghaus D, Blembel K, Waniek C, Kruells-Muench J, Ernst H, Kleemann T, Geller JC. Temperature monitoring and temperature-driven irrigated radiofrequency energy titration do not prevent thermally induced esophageal lesions in pulmonary vein isolation: A randomized study controlled by esophagoscopy before and after catheter ablation. Heart Rhythm 2021; 18:926-934. [PMID: 33561587 DOI: 10.1016/j.hrthm.2021.02.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 01/30/2021] [Accepted: 02/01/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Endoscopically detected esophageal lesions (EDELs) are common following pulmonary vein isolation (PVI) and may progress to atrioesophageal fistula (AEF). OBJECTIVE The purpose of this study was to study (1) the benefit of luminal esophageal temperature (LET) monitoring and (2) the impact of esophagogastroduodenoscopy (EGD) in detecting EDEL and defining pre-existing lesions. The primary endpoint was the number of ablation-induced lesions. METHODS Patients with atrial fibrillation were randomized to PVI with LET monitoring (LET[+]) or without LET monitoring (LET[-]). All patients underwent EGD before and after PVI. Ablation power at the left atrial (LA) posterior wall was limited to 25 W in all patients and was titrated to a minimum of 10 W guided by esophageal temperature in the LET[+] group. RESULTS Eighty-six patients (age 67 ± 10 years; 57% male) were included (44 LET[+], 42 LET[-]). PVI was achieved in all, and additional linear LA lesions were done in 50%. Eight patients developed EDEL (6 LET[+], 2 LET[-]; P = NS). Whereas LET <41°C did not differentiate with regard to EDEL formation, temperature overshooting ≥42°C was associated with a higher risk for new EDEL. Two-thirds of patients showed incidental findings (esophagitis, gastric ulcer) on preprocedural EGD; 8 esophageal lesions were pre-existing. Four patients in the LET[+] group developed epistaxis following insertion of the probe. CONCLUSION Monitoring of LET does not prevent ablation-induced esophageal lesions. Patients without temperature surveillance were not at higher risk, but temperatures ≥42°C were associated with increased likelihood of mucosal lesions.
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Affiliation(s)
| | - Kai Blembel
- Department of Cardiology, Carl-Thiem-Hospital Cottbus, Germany
| | - Claudia Waniek
- Department of Cardiology, Carl-Thiem-Hospital Cottbus, Germany; Thiem Research, Carl-Thiem-Hospital Cottbus, Germany
| | | | - Helmut Ernst
- Department of Gastroenterology, Carl-Thiem-Hospital Cottbus, Germany
| | - Tobias Kleemann
- Department of Gastroenterology, Carl-Thiem-Hospital Cottbus, Germany
| | - J Christoph Geller
- Division of Cardiology, Arrhythmia Section, Zentralklinik Bad Berka, Germany; Otto-von-Guericke University School of Medicine, Magdeburg, Germany
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35
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Kar R, Post A, John M, Rook A, Razavi M. An initial ex vivo evaluation of temperature profile and thermal injury formation on the epiesophageal surface during radiofrequency ablation. J Cardiovasc Electrophysiol 2021; 32:704-712. [PMID: 33476464 DOI: 10.1111/jce.14911] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 01/06/2021] [Accepted: 01/10/2021] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Few studies have examined heat transfer and thermal injury on the epiesophageal surface during radiofrequency application, or compared the risk of esophageal thermal injury between standard and high-power, short-duration (HPSD) ablation. We studied the thermodynamics of HPSD and standard ablation at different tissue interfaces between the left atrium and esophagus, focusing on epiesophageal temperature changes and thermal injury. METHODS AND RESULTS Fresh porcine heart and esophageal sections were secured to a custom holder and submerged in a temperature-controlled, circulating water bath. During ablation, thermistors recorded temperatures at the catheter tip-atrial interface, epiesophageal-atrial interface, and esophageal lumen. Samples were ablated in triplicate with the following parameters: contact force (15/25g), power (10/20/30 W standard; 40/45/50 W HPSD), and duration (10/20/30 s standard; 5/10/15 s HPSD). Epiesophageal and endoluminal temperature rises were greater in HPSD than in standard ablation (epiesophageal: 5.9 ± 5.6 vs. 2.2 ± 2.0°C, p < .01; endoluminal: 0.7 ± 0.5 vs. 0.4 ± 0.2°C, p < .01). Six of 30 HPSD ablations and 1 of 26 standard ablations caused esophageal injury. The delay between the peak epiesophageal and endoluminal temperatures was greater in HPSD than in standard ablation (24.2 ± 22.1 vs. 13.0 ± 11.0 s, p = .023). Likewise, the peak epiesophageal surface temperature differed more from the concurrent endoluminal temperature in HPSD ablation (5.1 ± 5.3 vs. 1.7 ± 2.0°C, p < .01). CONCLUSION Endoluminal temperature underestimates epiesophageal surface temperature substantially during HPSD ablation. Visible epiesophageal injury was associated with a 2.2 ± 2.1°C rise in endoluminal temperature, corresponding to a 10.2 ± 6.5°C rise in epiesophageal temperature.
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Affiliation(s)
- Ronit Kar
- Department of Biomedical Engineering, The University of Texas at Austin, Austin, Texas, USA.,Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas, USA
| | - Allison Post
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas, USA
| | - Mathews John
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas, USA
| | - Ashley Rook
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas, USA
| | - Mehdi Razavi
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas, USA.,Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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Jankelson L, Dai M, Aizer A, Bernstein S, Park DS, Holmes D, Chinitz LA, Barbhaiya C. Lesion Sequence and Catheter Spatial Stability Affect Lesion Quality Markers in Atrial Fibrillation Ablation. JACC Clin Electrophysiol 2021; 7:367-377. [PMID: 33516716 DOI: 10.1016/j.jacep.2020.09.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 09/03/2020] [Accepted: 09/23/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES This study sought to analyze high-frequency catheter excursion in relation to lesion quality markers in 20 consecutive patients undergoing first-time radiofrequency (RF) ablation for paroxysmal atrial fibrillation (AF). BACKGROUND Ablation therapy for AF requires the delivery of durable lesions. The extent to which lesion sequence, catheter spatial stability, and anatomic location influence lesion formation during RF ablation of AF is not well understood. METHODS Three-dimensional spatial excursion of the ablation catheter sampled at 60 Hz during pre-specified pairs of RF lesions was extracted from the CARTO3 System (Biosense Webster Inc., Irvine, California) and analyzed by using custom-developed MATLAB software (MathWorks, Natick, Massachusetts) to define precise catheter spatial stability during RF ablation. Ablation parameters including bipolar electrogram amplitude reduction, impedance decline and transmurality-associated unipolar electrogram (TUE) as evidence of lesion transmurality during lesion placement were recorded and analyzed. RESULTS We collected 437,760 position data points during lesion placement. Ablation catheter spatial stability and lesion formation parameters varied considerably by anatomic location. Lesions placed immediately had similar bipolar electrogram amplitude reduction, smaller impedance decline, but higher likelihood of achieving TUE compared to delayed lesions. Greater catheter spatial stability correlated with lesser impedance decline. CONCLUSIONS Lesion sequence, ablation catheter spatial stability, and anatomic location are important modifiers of RF lesion formation. Lesions placed immediately are more likely to exhibit TUE. Greater ablation catheter stability is associated with lesser impedance decline but greater likelihood of TUE.
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Affiliation(s)
- Lior Jankelson
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York University School of Medicine, New York, New York, USA.
| | - Matthew Dai
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York University School of Medicine, New York, New York, USA
| | - Anthony Aizer
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York University School of Medicine, New York, New York, USA
| | - Scott Bernstein
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York University School of Medicine, New York, New York, USA
| | - David S Park
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York University School of Medicine, New York, New York, USA
| | - Douglas Holmes
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York University School of Medicine, New York, New York, USA
| | - Larry A Chinitz
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York University School of Medicine, New York, New York, USA
| | - Chirag Barbhaiya
- Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York University School of Medicine, New York, New York, USA
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Piringer R, Deneke T, Foldyna B, Sonne K, Nentwich K, Ene E, Barth S, Lüsebrink U, Berkovitz A, Halbfass P. Incidence of ablation-induced esophageal injury associated with high-power short duration temperature-controlled pulmonary vein isolation using a specialized open-irrigated ablation catheter: A retrospective single-center study. J Cardiovasc Electrophysiol 2021; 32:695-703. [PMID: 33442930 DOI: 10.1111/jce.14883] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 12/24/2020] [Accepted: 01/04/2021] [Indexed: 01/01/2023]
Abstract
INTRODUCTION To evaluate short-term efficacy and incidence of ablation-induced endoscopically detected esophageal injury in patients undergoing high-power, short-duration (HPSD) pulmonary vein isolation using a novel irrigated radiofrequency ablation catheter and ablation generator setup. METHODS AND RESULTS Atrial fibrillation (AF) patients, who underwent AF ablation using an irrigated radiofrequency ablation catheter specifically designed for a HPSD ablation approach (50 W, with a target Ablation Index of 350 at posterior wall), received postablation esophageal endoscopy after ablation. In total 45 consecutive patients (67 ± 10 years; 58% male; 42% paroxysmal AF) undergoing AF ablation using a specialized ablation catheter (QDOT) were included in the study. Thirty-one of 45 patients (69%) underwent a first-time pulmonary vein isolation (Group 1, 67 ± 11 years; 55% male; 48% paroxysmal AF). Fourteen patients (31%) underwent a redo AF procedure (Group 2, 66 ± 8 years; 64% male; 29% paroxysmal AF). Patients undergoing first-time pulmonary vein isolation were included in the final analysis. In these patients an endoscopically detected esophageal lesion (EDEL) was detected in 5 of 31 (16%) patients (erosion n = 2, ulcer n = 3). Mean contact force at posterior wall ablation sites was significantly lower in patients with postprocedural EDEL compared with patients without EDEL (11.9 ± 0.8 g vs. 15.6 ± 4.7 g). CONCLUSION PVI using a specialized high-power ablation catheter in conjunction with a HPSD ablation approach results in a 16% incidence of EDEL in first AF ablation candidates. Future studies evaluating high-power short duration ablation strategies should include esophageal endoscopy to estimate the risk of clinically relevant esophageal complications.
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Affiliation(s)
| | - Thomas Deneke
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Borek Foldyna
- Clinic for Diagnostic and Interventional Radiology, Heart Center Bad Neustadt a.d. Saale, Bad Neustadt a.d. Saale, Germany.,Cardiovascular Imaging Research Center, Massachusetts General Hospital - Harvard Medical School, Boston, Massachusetts, USA
| | - Kai Sonne
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Karin Nentwich
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Elena Ene
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Sebastian Barth
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Ulrich Lüsebrink
- Department of Cardiology and Angiology, Philipps-University Marburg, Marburg, Germany
| | - Artur Berkovitz
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Philipp Halbfass
- Clinic for Invasive Electrophysiology, Heart Center Bad Neustadt, Bad Neustadt a.d. Saale, Germany.,Department of Cardiology and Angiology, Philipps-University Marburg, Marburg, Germany
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38
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Catheter ablation of atrial fibrillation using ablation index–guided high power (50 W) for pulmonary vein isolation with or without esophageal temperature probe (the AI-HP ESO II). Heart Rhythm 2020; 17:1833-1840. [DOI: 10.1016/j.hrthm.2020.05.029] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 01/21/2023]
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Barbhaiya CR. High-Power Short-Duration Ablation. JACC Clin Electrophysiol 2020; 6:1262-1264. [DOI: 10.1016/j.jacep.2020.06.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 06/29/2020] [Accepted: 06/29/2020] [Indexed: 11/16/2022]
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Kaneshiro T, Kamioka M, Hijioka N, Yamada S, Yokokawa T, Misaka T, Hikichi T, Yoshihisa A, Takeishi Y. Characteristics of Esophageal Injury in Ablation of Atrial Fibrillation Using a High-Power Short-Duration Setting. Circ Arrhythm Electrophysiol 2020; 13:e008602. [PMID: 32915644 DOI: 10.1161/circep.120.008602] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The mechanism of esophageal thermal injury (ETI; esophageal mucosal injury and periesophageal nerve injury leading to gastric hypomotility) remains unknown when using a high-power short-duration (HP-SD) setting. This study sought to evaluate the characteristics of esophageal injuries in atrial fibrillation ablation using a HP-SD setting. METHODS After exclusion of 5 patients with their esophagus at the right portion of left atrium and 21 patients with additional ablations such as box isolation and low voltage area ablation in left atrium posterior wall, 271 consecutive patients (62±10 years, 56 women) who underwent pulmonary vein isolation by radiofrequency catheter ablation were analyzed. In the 101 patients, a HP-SD setting at 45 to 50 W with an Ablation Index module was used (HP-SD group). In the remaining 170 patients before introduction of the HP-SD setting, a conventional power setting of 20 to 30 W with contact force monitoring was used (conventional group). We performed esophagogastroduodenoscopy after pulmonary vein isolation in all patients and investigated the incidence and characteristics of ETI. RESULTS Although the incidence of ETI was significantly higher in the HP-SD group compared with the conventional group (37% versus 22%, P=0.011), the prevalence of esophageal lesions did not differ between the groups (7% versus 8%). Multivariate logistic regression analysis revealed that the use of the HP-SD setting (odds ratio, 6.09, P<0.001), and the parameters that suggest anatomic proximity surrounding the esophagus, were independent predictors of ETI. However, the majority of ETI in the HP-SD group was gastric hypomotility, and the thermal injury was limited to the shallow layer of the periesophageal wall using the HP-SD setting. CONCLUSIONS Although the use of the HP-SD setting was a strong predictor of ETI, it could avoid deeper thermal injuries that reach the esophageal mucosal layer.
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Affiliation(s)
- Takashi Kaneshiro
- Department of Cardiovascular Medicine (T.K., M.K., N.H., S.Y., T.Y., T.M., A.Y., Y.T.), Fukushima Medical University, Japan
- Department of Arrhythmia and Cardiac Pacing (T.K., Y.T.), Fukushima Medical University, Japan
| | - Masashi Kamioka
- Department of Cardiovascular Medicine (T.K., M.K., N.H., S.Y., T.Y., T.M., A.Y., Y.T.), Fukushima Medical University, Japan
| | - Naoko Hijioka
- Department of Cardiovascular Medicine (T.K., M.K., N.H., S.Y., T.Y., T.M., A.Y., Y.T.), Fukushima Medical University, Japan
| | - Shinya Yamada
- Department of Cardiovascular Medicine (T.K., M.K., N.H., S.Y., T.Y., T.M., A.Y., Y.T.), Fukushima Medical University, Japan
| | - Tetsuro Yokokawa
- Department of Cardiovascular Medicine (T.K., M.K., N.H., S.Y., T.Y., T.M., A.Y., Y.T.), Fukushima Medical University, Japan
| | - Tomofumi Misaka
- Department of Cardiovascular Medicine (T.K., M.K., N.H., S.Y., T.Y., T.M., A.Y., Y.T.), Fukushima Medical University, Japan
| | - Takuto Hikichi
- Department of Endoscopy (T.H.), Fukushima Medical University, Japan
| | - Akiomi Yoshihisa
- Department of Cardiovascular Medicine (T.K., M.K., N.H., S.Y., T.Y., T.M., A.Y., Y.T.), Fukushima Medical University, Japan
- Department of Advanced Cardiac Therapeutics (A.Y., Y.T.), Fukushima Medical University, Japan
| | - Yasuchika Takeishi
- Department of Cardiovascular Medicine (T.K., M.K., N.H., S.Y., T.Y., T.M., A.Y., Y.T.), Fukushima Medical University, Japan
- Department of Arrhythmia and Cardiac Pacing (T.K., Y.T.), Fukushima Medical University, Japan
- Department of Advanced Cardiac Therapeutics (A.Y., Y.T.), Fukushima Medical University, Japan
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Candemir B, Baskovski E, Mammadov M, Esenboga K, Altin T. Triple gastrointestinal prophylactic therapy following high-power short-duration posterior left atrial wall ablation. Indian Heart J 2020; 72:306-308. [PMID: 32861390 PMCID: PMC7474111 DOI: 10.1016/j.ihj.2020.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/18/2020] [Accepted: 06/21/2020] [Indexed: 11/28/2022] Open
Abstract
The purpose of this study is to investigate incidence of gastrointestinal symptoms and complications in patients who underwent high-power short-duration (HPSD), posterior left atrial wall isolation during atrial fibrillation ablation and thereafter have received gastrointestinal prophylactic regimen consisting of sucralfate, proton-pump inhibitor and colchicine. Patients were followed and assessed at baseline, up until 6th month following the procedures.Among 115 patients who were included, 5 patients (4.3%) reported gastrointestinal symptoms at follow-up. No complications were diagnosed during the follow-up. In conclusion, the HPSD along with prophylactic regimen has been associated with low incidence of gastrointestinal adverse events.
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Schoene K, Arya A, Grashoff F, Knopp H, Weber A, Lerche M, König S, Hilbert S, Kircher S, Bertagnolli L, Dinov B, Hindricks G, Halm U, Zachäus M, Sommer P. Oesophageal Probe Evaluation in Radiofrequency Ablation of Atrial Fibrillation (OPERA): results from a prospective randomized trial. Europace 2020; 22:1487-1494. [DOI: 10.1093/europace/euaa209] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 07/10/2020] [Indexed: 11/12/2022] Open
Abstract
Abstract
Aims
The aim of the study was to determine the incidence of oesophageal lesions after radiofrequency ablation (RFA) of atrial fibrillation (AF) with or without the use of oesophageal temperature probes.
Methods and results
Two hundred patients were prospectively randomized into two groups: the OPERA+ group underwent RFA using oesophageal probes (SensiTherm™); the OPERA− group received RFA using fixed energy levels of 25 W at the posterior wall without an oesophageal probe. All patients underwent post-interventional endoscopy and Holter-electrocardiogram after 6 months. (Clinical.Trials.gov: NCT03246594). One hundred patients were randomized in OPERA+ and 100 patients in OPERA−. The drop-out rate was 10%. In total, 18/180 (10%) patients developed endoscopically diagnosed oesophageal lesions (EDEL). There was no difference between the groups with 10/90 (11%) EDEL in OPERA+ vs. 8/90 (9%) in OPERA− (P = 0.62). Despite the higher power delivered at the posterior wall in OPERA+ [28 ± 4 vs. 25 ± 2 W (P = 0.001)], the average EDEL size was equal [5.7 ± 2.6 vs. 4.5 ± 1.7 mm (P = 0.38)]. The peak temperature did not correlate with EDEL size. During follow-up, no patient died. Only one patient in OPERA− required a specific therapy for treatment of the lesion. Cumulative AF recurrence after 6 (3–13) months was 28/87 (32%) vs. 34/88 (39%), P = 0.541.
Conclusion
This first randomized study demonstrates that intraoesophageal temperature monitoring using the SensiTherm™ probe does not affect the probability of developing EDEL. The peak temperature measured by the thermoprobe seems not to correlate with the incidence of EDEL. Empiric energy reduction at the posterior wall did not affect the efficacy of the procedure.
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Affiliation(s)
- Katharina Schoene
- Department of Electrophysiology, Heart Center, University of Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany
- Leipzig Heart Institute GmbH, Leipzig, Germany
| | - Arash Arya
- Department of Electrophysiology, Heart Center, University of Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany
| | | | | | | | - Matthias Lerche
- Department of Electrophysiology, Heart Center, University of Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany
| | - Sebastian König
- Department of Electrophysiology, Heart Center, University of Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany
| | - Sebastian Hilbert
- Department of Electrophysiology, Heart Center, University of Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany
| | - Simon Kircher
- Department of Electrophysiology, Heart Center, University of Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany
| | - Livio Bertagnolli
- Department of Electrophysiology, Heart Center, University of Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany
| | - Borislav Dinov
- Department of Electrophysiology, Heart Center, University of Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center, University of Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany
- Leipzig Heart Institute GmbH, Leipzig, Germany
| | | | | | - Philipp Sommer
- Herz- und Diabetes Zentrum NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
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Jiang R, Zei PC, Jiang C. Prevention of left atrium esophagus fistula: Appraisal of existing technologies and strategies. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:646-654. [PMID: 32391576 DOI: 10.1111/pace.13939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/27/2020] [Accepted: 05/08/2020] [Indexed: 12/17/2022]
Abstract
Catheter ablation has emerged as an effective treatment for atrial fibrillation (AF). Atrial esophageal fistula (AEF) is a rare, but feared complication. With increasing utilization of ablation therapy for AF, the understanding of the relationship between AEF and ablation has been improved in recent years. Efforts to reduce the risk of AEF have focused on decreasing the risk of severe esophageal injury (EI) and the presumed subsequent progression from EI to AEF, including esophageal temperature monitoring, esophageal cooling systems, esophageal deviation devices, and decreasing and/or curtailing ablation energy delivery. Periprocedural assessment may help identify higher risk patients and detect early esophageal lesions. This review systematically summarizes and evaluates the current strategies and techniques utilized to reduce the risk of AEF in the clinical workflow for AF ablation. We expect that this review will help clinicians to better understand the principles, advantages, and disadvantages of these methods, and to find suitable strategies using current available tools.
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Affiliation(s)
- Ruhong Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine, Hangzhou, Zhejiang, China.,Comprehensive Unit of National Regional Medical Center, Zhejiang, China
| | - Paul C Zei
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Chenyang Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Cardiovascular Intervention and Regenerative Medicine, Hangzhou, Zhejiang, China.,Comprehensive Unit of National Regional Medical Center, Zhejiang, China
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